, hereby authorize the use or disclosure of my protected health information as described below:
1. AUTHORIZED PERSONS TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
is authorized to disclose the following protected health information to my Physical Therapist, Dr. Nikki Robinett, PT, DPT at Moving & Grooving Pediatric Physical Therapy of Scottsdale,
All past, present, and future periods of health care information may be shared.
3. PURPOSE OF THE USE OR DISCLOSURE
The purpose of this use or disclosure is so that my child's physical therapist has all pertinent information..
4. VALIDITY OF AUTHORIZATION FORM
This Authorization Form is valid beginning on
and expires When the child is discharged from physical therapy.
5 ACKNOWLEDGMENT
I understand that the information used or disclosed under this Authorization Form may be subject to re- disclosure by the person(s) or facility receiving it and would then no longer be protected by federal privacy regulations.
I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
I have the right to refuse to sign this Authorization Form. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.
Signed of behalf of
by
, patient's
